Department of the Treasury - Internal Revenue Service
Form 14095                                                                                                          OMB Number 
   (August 2020)             The Health Coverage Tax Credit (HCTC)                                                  1545-2152
                                                Reimbursement Request
Use this form to request a reimbursement for premiums you paid directly to a qualified health plan for any month in the current calendar 
year while you were eligible for but not enrolled in the HCTC Advanced Monthly Payment (AMP) program. The IRS can consider your 
request only if you are eligible to participate in the HCTC AMP program in the coverage month you are requesting and have made at 
least one premium payment through the program in the current calendar year.
Instructions
1. Print or type your responses. Complete all parts of this form. 
2. Provide verifiable proof that your health plan is qualified for the Health Coverage Tax Credit and that you paid the qualified health 
   insurance premiums by attaching the required supporting documents to your Reimbursement Request form.
3. Mail the completed form and required supporting documents to: Internal Revenue Service  
                                                                  Stop 6098 AUSC  
                                                                  Austin, TX 78741 
4. Ensure the IRS receives your completed Form 14095 on or before September 30 of the current calendar year. Any amount that 
   cannot be reimbursed may be used to claim a HCTC credit on your federal tax return. See the Instructions for Form 8885, Health 
   Coverage Tax Credit.
NOTE: Once you mail the HCTC Reimbursement Request, it can take up to 12 weeks (if all requirements are met) before you receive 
your reimbursement.
5. NEXT: If your request is not approved, the HCTC Program will send a letter that explains why your request was denied.
Part 1: Provide Information About You
Your name (first, middle initial, last, suffix)                            Social security number (last four digits)

Your mailing address (street address)                                      City                         State           ZIP code

Telephone number                                                           HCTC participant identification number (from Letter 4545)

Part 2: Determine Eligibility and Request Reimbursement
You can request reimbursement for premiums you paid for qualified coverage while you were eligible but not enrolled in the HCTC 
AMP program. For each month of the current calendar year for which you are requesting reimbursement, all of the following statements 
must be true on the first day of that month.
• You were an eligible individual (an eligible Trade Adjustment Assistance (TAA), Alternative TAA (ATAA), or Reemployment TAA 
(RTAA) recipient, or a Pension Benefit Guaranty Corporation (PBGC) payee age 55 years or older), or were a Qualifying Family 
Member of an eligible TAA, ATAA, RTAA or a PBGC payee age 55 years or older.
•  You were covered by HCTC - qualified health insurance coverage for which you paid the premiums, or your portion of the premiums, 
directly to your health plan.
•  You were not enrolled in Medicare Part A, B, or C.
•  You were not enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).
•  You were not enrolled in the Federal Employees Health Benefits Program (FEHBP) or eligible to receive benefits under the U.S. 
military health system (TRICARE).
•  You were not imprisoned under federal, state, or local authority. 
•  Your or your spouse's employer (or former employer) did not pay 50% or more of the cost of coverage.
•  You cannot be claimed as a dependent on someone else’s federal income tax return.
Part 3: Request Reimbursement
Check the box for each month of the current calendar year for which you are requesting reimbursement. For each of those months, 
you must have made premium payments directly to a qualified health plan and meet all requirements stated in Part 2.
   January             February                 March                April                           May
   June                July                     August               September

Catalog Number 53672K                                  www.irs.gov                                      Form 14095 (Rev. 8-2020)

                                                                                                                                            Page 2
Enter the TOTALS for ALL MONTHS checked above
1. Enter the total amount you paid directly to your qualified health plan
2. Enter the total amount you paid for dental or vision benefits. These benefits do not qualify for the HCTC
3. Subtract line 2 from line 1. Enter the total
4. Enter total amount you paid for family members that are not qualified for the HCTC
5. Subtract line 4 from line 3. Enter the total
6. Multiply line 5 by 72.5% (0.725). Enter the total. This is your Total Requested Reimbursement
Part 4: Gather Supporting Documents
You must provide copies of the corresponding health insurance bills for the months identified in Part 3 of this form. These documents 
must show the following information: 
   •  Your name (or name of the policy holder)
   •  Social Security number of Policy Holder if different from requester
   •  The name of your health plan 
   •  Your monthly premium amount
   •  Dates of coverage
   •  Your health plan identification number(s) including member ID, Group ID, Policy or Plan ID
Note: If your qualified health plan does not provide members with an insurance bill or COBRA payment coupon, you must provide 
health plan enrollment documents or an official letter from your health plan that has the required information listed in the bullets above.
You must also provide proof that you paid those premiums. Acceptable proof of payment includes: 
   •  Canceled checks (copy of front and back)
   •  Bank statements
   •  Credit card statements
   •  Money Order receipts
Note: Your proof of payment must indicate the amount paid and to whom it was paid. If you do not have one of these types of proof of 
payment, contact your health plan for a record of your payment(s).
Part 5: Sign and Date This Form 
Under penalties of perjury, I declare that the information furnished on this form with regard to myself and to any family member(s), and 
any attachments to it, is true, correct, and complete. I understand that a knowing and willfully false statement on this form or any 
attachment to it can result in my disqualification from the HCTC AMP program. By signing, I authorize the IRS to independently discuss 
with my health insurer, third party administrator or former employer, my eligibility status and HCTC payments made on my behalf to 
these organizations.
Signature                                      Full name (print or type)                                    Date

If you have any questions about this form, contact the Internal Revenue Service toll-free at 1-844-853-7210.

Note: Only months during the current calendar year are eligible for reimbursement request. If you were eligible for the HCTC and made 
payments directly to your Health Plan for months prior to the current calendar year, you may be able to claim these amounts on your 
federal tax return for that year, see Form 8885 Instructions. 
                            Paperwork Reduction Act Notice And Privacy Act Statement
PAPERWORK REDUCTION ACT NOTICE. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your 
response is voluntary. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the 
form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become 
material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by code section 
6103. The estimated average time to complete this form is 15 minutes. If you have comments concerning the accuracy of this time estimate or 
suggestions for making this form simpler, we will be happy to hear from you. You can write to the Tax Products Coordinating Committee, SE:W:CAR:
MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224. 
PRIVACY ACT STATEMENT. The following information is provided to comply with the Privacy Act of 1974 (P.L.93-579). All information collected on this 
form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. We use the information you submit to determine if you qualify for 
reimbursement of the monthly credit of the Health Coverage Tax Credit (HCTC). If you fail to provide the information, or provide inaccurate information, 
your application may be denied. However, you may still qualify for the Yearly HCTC when you file your federal income tax return.
Catalog Number 53672K                                         www.irs.gov                                   Form 14095 (Rev. 8-2020)